Companies providing pharmacy benefit management services, known as “PBMs,” provide prescription drug program administration to health plans and/or employer groups. As part of the processing agreement with the health plan providers and/or employer groups, PBMs charge a percentage fee in excess of the cost reimbursed to the dispenser of the prescription item. This fee, often referred to as a “spread,” is typically a single digit percentage in the range of 2%-4%.
It is a concern of health plan providers, employer groups, as well as PBMs themselves that some PBMs may not be calculating the spread value correctly. Some PBMs may even manipulate the reimbursement data to ensure that the calculation of spread values results in larger spread values than otherwise should be paid under the contractual arrangement. For instance, it is believed that one technique used to maximize the spread value involves delaying the use of price updates used in pharmacy reimbursement calculations while using an updated price (which is higher than the previous price) in spread calculations, thereby increasing the spread value beyond the contractual arrangement.